Annette,
Great summary of steps to take on a corrective action plan. Then it just requires monitoring and tracking to ensure the responsible individuals meet their deadlines.
Traci Lee
A Corrective Action Plan for an audit finding should have detailed components to it. If there are multiple findings each finding should should be numbered, have a title for the finding and then a summary of the finding that needs to be rectified.
There should be a response of the corrective action that will take place and how these actions will be implemented.
The responsible person or department should be identified and the due date to be completed.
Procedures should be put in place to prevent the infractions from reoccuring.
Any shortcoming should be address in the Corrective Action Plans (CAP). The department head should provide a training program as a way to correct future incidents as part of the CAP.
Every member in that department should realize the shorcoming and a way to prevent future actions.
A corrective action plan submitted by a campus in response to audit findings needs to include a summary of the findings with specific action items necessary to correct or respond to each finding.
The specific action items may include new policies and procedures when necessary and will need to include the purpose and responsible positions to uphold the polices and procedures.
Corrective action item will also require a specific timeline for implementation of action or change that lead to the correction right away or over time.
For responses to findings that require formal documentation indicating a finding has been corrected, the "proof" must be comprehensive and applicable.
It depends on the issue that needs to be corrected.
Short term and vital issues should identify the problem, the source of the problem the reason(s) for the problem and the procedural steps that are to be implemented. Then some reasonable test should be conducted to try to ensure that the correction did take place.
Isssues that are measured over a longer period of time would require all of the above steps, as well as some intermediate steps to encourage progress toward the solution. The intermediate steps should be subject to some reasonable test along with a test of the ultimate goal.
Jennifer,
Well stated - a good audit response can be understood by anyone without knowing the details of this history of the finding/observation.
Traci Lee
Very detailed list. It is very important to have a thorough and clear corrective action plan so it may be a "stand alone" document.
I would want a description of the original finding. A breakdown of steps to correct this finding and how to avoid this in the future. Once creating a new procedure I would implement it into my operations manual.
Thanks, I am taking it all down for future reference.
I believe this is a pretty comprehensive list!
I am new to becoming the dean at my school, and while being the assistant I was minimally exposed to audits I will be answering to them in the near future.
The school I work for has been in business for over 30 years and I am sure they have this type of detailed list for such matters.
Luckily we have not been sited for many, many years.... (I hope I didn't just jinx myself!)
John,
Great point - there is a big difference between an isolated error and a systemic problem that requires revising policies and/or processes and procedures.
Traci Lee
Generally, a corrective action plan not only addresses the individual finding but a response to any systemic issue. The auditor is only reviewing a small sample of all of the activity so when there is a finding it raises the issue that there is a deficiency in the internal policies and controls.
A campus or department should include a specific response to the finding but also a clarification on what changes, if any, they will make to their systems to make sure the finding does not happen again.
An action plan should include at minimum the following:
•The description of the failed test.
•The number of exceptions found
•The threshold before the test is considered a fail test
•The detail information of each exceptions.
•The team member directly responsible of each test.
•How the team member will resolve the current issue and the plan to prevent the same item in the future
•The timeline of the implementation, and
•A follow up time line from the audit team.
•Signatures and date
Isabel,
I think it's great to be prepared - I also think it's good to be organized proactively as sometimes, even if notice is provided, there may not be enough time to completely get things in order if there is a lot to do to organize.
Traci Lee
I would quickly correct any issues found, during the audit, to keep my campus compliant. It's important to be prepared for an audit. We always have notice before a visit and preparing for it keeps us organized for the audit.
In response to an audit finding, I think the following should be included in a corrective action plan:
The Auditors’ name
Date of the finding
The finding
Responsible party
Circumstances that led to the finding
Detailed information on correcting the finding
Estimated time frame for follow up
Citation number, if applicable
In addition to the list of items provided in previous reponses an action plan should include processes in place to prevent issues from reoccuring. Policies should be drafted, catalogs updates, etc. If errors, evidence they have been addressed and corrected.
Audit findings and the corrective action plans should be given to all employees involved. When this action is taken the solution,with the involvement of more employees can sometimes be very simple.
I think a corrective plan should first acknowledge the findings and then list a plan of action for each correction and a timeframe for which they will be corrected along with a plan of action to monitor and ensure that this wont happen again.
In any case; alot of times auditors provide a checklist of what needs to be corrected, they provide a certain amount of time for corrective action. At my University we take immediate action to reply on deficiences and correct the issue.
